Tonsillar Asymmetry and Malignancy: A Meta-analysis of Diagnostic Accuracy.
To investigate the diagnostic utility of asymmetrical tonsils in detecting tonsillar malignancy.
PubMed, Embase, Scopus, and Cochrane Library; from inception until December 17, 2024.
We included observational studies of adult/pediatric patients undergoing excisional tonsillectomy or incisional tonsillar biopsy that reported at least one diagnostic accuracy outcome for tonsillar asymmetry in predicting malignancy. We pooled estimates using frequentist univariate random-effects generalized linear mixed models, examined and adjusted for publication bias via visual inspection, Egger's test, and trim-and-fill, performed influence and cumulative meta-analyses, and used a Bayesian bivariate model as a sensitivity analysis. Outcome measures included the following: sensitivity, specificity, positive/negative likelihood ratio (LR+/LR-), and positive/negative predictive value (NPV/PPV) with 95% confidence interval (95% CI).
Twenty-nine studies (5178 participants) from 422 records were included. The risk of bias was low-moderate. The sensitivity and specificity of tonsillar asymmetry as a diagnostic marker for malignancy were 77.2% (95% CI: 68.6%-84.0%) and 96.4% (95% CI: 91.6%-98.6%), respectively. The LR- was 0.24 (0.17-0.34) and LR+ was 21.44 (8.05-57.0). The NPV and PPV were 99.8% (95% CI: 99.1%-99.9%) and 4.31% (95% CI: 1.83%-9.80%), without considering clinical risks. With concomitant high-risk clinical features such as lymphadenopathy, the PPV (probability of malignancy given asymmetrical tonsils) was 38.5% (30.3%-47.4%). Without other high-risk features, the PPV was 0.16% (0.15%-0.18%). The overall quality of evidence was high.
Tonsillar asymmetry has a high specificity and moderate sensitivity for tonsillar malignancy. Due to the low prevalence of malignancy, the probability of malignancy is less than 1% if no other suspicious clinical features are present.
PubMed, Embase, Scopus, and Cochrane Library; from inception until December 17, 2024.
We included observational studies of adult/pediatric patients undergoing excisional tonsillectomy or incisional tonsillar biopsy that reported at least one diagnostic accuracy outcome for tonsillar asymmetry in predicting malignancy. We pooled estimates using frequentist univariate random-effects generalized linear mixed models, examined and adjusted for publication bias via visual inspection, Egger's test, and trim-and-fill, performed influence and cumulative meta-analyses, and used a Bayesian bivariate model as a sensitivity analysis. Outcome measures included the following: sensitivity, specificity, positive/negative likelihood ratio (LR+/LR-), and positive/negative predictive value (NPV/PPV) with 95% confidence interval (95% CI).
Twenty-nine studies (5178 participants) from 422 records were included. The risk of bias was low-moderate. The sensitivity and specificity of tonsillar asymmetry as a diagnostic marker for malignancy were 77.2% (95% CI: 68.6%-84.0%) and 96.4% (95% CI: 91.6%-98.6%), respectively. The LR- was 0.24 (0.17-0.34) and LR+ was 21.44 (8.05-57.0). The NPV and PPV were 99.8% (95% CI: 99.1%-99.9%) and 4.31% (95% CI: 1.83%-9.80%), without considering clinical risks. With concomitant high-risk clinical features such as lymphadenopathy, the PPV (probability of malignancy given asymmetrical tonsils) was 38.5% (30.3%-47.4%). Without other high-risk features, the PPV was 0.16% (0.15%-0.18%). The overall quality of evidence was high.
Tonsillar asymmetry has a high specificity and moderate sensitivity for tonsillar malignancy. Due to the low prevalence of malignancy, the probability of malignancy is less than 1% if no other suspicious clinical features are present.
Authors
Gao Gao, See See, Tan Tan, Chan Chan, Zhou Zhou, See See, Kiong Kiong, Chan Chan, Koh Koh, Tan Tan, Abhilash Abhilash, Lim Lim
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